SOC .
 13 CODE

3RD MONTH 

1.Total Taxes Due

    LOCATION .
YOU CAN FILE THIS REPORT ONLINE AT DES.NC.GOV NC DEPT. OF COMMERCE DIVISION OF EMPLOYMENT SECURITY P.0. BOX 26504 RALEIGH, NC 27611-6504 2ND MONTH 12 SUMMARY

NUMBER OF COVERED WORKERS WHO WORKED DURING OR RECEIVED  2. 1ST MONTH EMPLOYEE/ 11.
OFFICER
PAY FOR THE PAYROLL PERIOD WHICH INCLUDES THE 12TH OF THE MONTH
/Yr r * DATE
Qt
 WAGE 
10. STATUS
RS
ACCOUNT NUMBER OU
 H9. WORKED
  % 
 . 
OUT OF 8. 
STATE CODE
ACCOUNT NUMBER TELEPHONE NUMBER
INITIAL LPP.W
DUE DATE  
 
OUT OF STATE  .7
TAXABLE WAGES $ 0.00

TAX RATE     COLL LFP.W  
DO NOT USE THIS FORM IF REPORTING 10 OR MORE WAGE ITEMS
AGENCY USE
6. GROSS WAGES DES.NC.GOV 
WAGE REPORT QUARTERLY TAX AND EMPLOYER'S * $ 0.00
INDICATES A REQUIRED FIELD QUARTER ENDING DATE R/CK
*

ONLINE AT
14.TOTALS TITLE
DUE DATE 
YOU CAN FILE THIS REPORT 
 NAME
 FIRST
5.
EMPLOYER'S QUARTERLY TAX AND WAGE REPORT *
THIS REPORT MUST BE FILED BY THE DUE DATE TO AVOID PENALTIES AND INTEREST
   
HERE:

NAME
A PENALTY WILL BE APPLIED TO  ANY REPORTS THAT CONTAIN 10 OR MORE WAGE ITEMS  NUMBER  
LAST  4. QUARTER ENDING HE  INFORMATION  CONTAINED  IN  THIS  REPORT  IS  TRUE  AND  CORRECT  TO  THE  BEST  OF  MY  KNOWLEDGE.  
* T
SIGNATURE
NCUI 101

CHECK THIS BOX IF THE ADDRESS HAS CHANGED
/23
SSN. 11
3
ENTER YOUR FEDERAL TAX IF ANY CHANGES OCCURRED IN THE OWNERSHIP, TELEPHONE NUMBER OR  ADDRESS, COMPLETE FORM NCUI 101-A. * REV 

         INSTRUCTIONS FOR COMPLETING FORM NCUI 101, EMPLOYERS QUARTERLY REPORT 
         Do not use this form if reporting 10 or more wage items, go to des.nc.gov to file your report online. 

         ITEM 1:  Enter The Total Taxes Due For The Quarter. 
         ITEM 2:  Enter The Number Of Covered W orkers Who W orked During Or Received 
         Pay For The Payroll Period Which Includes The 12th Of The Month 
         ITEM 3: Enter The Federal Social Security Number Of Every W orker Whose  
         W ages Are Reported On This Form. The Employee’s SSN As Shown On 
         The Original/Replacement SSN Card Issued By SSA.    
         ITEM 4: Enter The Employee’s Last Name As Shown On SSN Card, Of Every W orker 
         Whose W ages Are Reported On This Form. 
         ITEM 5: Enter The Employee’s First Name As Shown On SSN Card, Of Every Worker Whose 
         Wages Are Reported On This Form. 
         ITEM 6: Enter the Gross Wages 
         ITEM 7: Enter The Out of State (OOS) Wage Amount For The Employee Whose Wages Are 
         Countable, In Another State. If There Are No Out-Of-State Wages, Enter “0’s. 
         ITEM 8: Enter The Out of State (OOS) Wage Code. The OOS Wage Code Of 
         Commonwealth/Territory. Use Postal Abbreviations. 
         https://www.des.nc.gov/documents/files/suits-wage-report-and-payment-file-specification/open (Specification and
         Record Layout for Wage Reporting, Adjustments and Payments -Section 10.6)     
         ITEM 9: Enter The Hours Worked During Quarter For The Employee. Total Wages and Hours 
         Worked Cannot Both Equal Zero For An Original Filing 
         ITEM 10: Enter Whether The W age Record W as Added, Changed, Or Deleted 
         ITEM 11:Enter Whether Employee Or Officer 
         ITEM 12:Enter the Site Location Where An Employee Specifically W orks Or the Unit To Which The Employee Is Attributed 
         ITEM 13: Enter the State Occupation Code (SOC) Code Of Employee https://www.bls.gov/oes/current/oes_stru.htm   
         ITEM 14: Page Totals. 

REV 11/23

                                                       Instructions to Calculate the Taxable Wage Amount 
         1: Enter all wages paid to all employees, including part-time and temporary, in this calendar quarter. If the legal business is: 

              (A) CORPORATION, the wages paid to all employees who performed services in North Carolina should be reported. Corporate officers are employees and their wages
              and/or draws are reportable.
              (B)  A PARTNERSHIP, the draws or payments made to general partners should not be reported.
              (C)  A PROPRIETORSHIP, the draws or payments made to the legal owner of the business (the proprietor) should not be reported. W age paid to the children of the
              proprietor under the age of 21 years, as well as wages paid to the spouse or parents of the proprietor, should not be reported.

              Special payments given in return for services performed, I.E., commissions, bonuses, fees, prizes, are wages and reportable under the Employment Security Law of 
              North Carolina. These payments (or dollar value of the gifts/prizes) are to be included in the payroll of each employee by the employer for the calendar quarter(s) in 
              which they are given. If no wages were paid, enter NONE. 

         2: Enter the amount of wages paid during this quarter that is in excess of the applicable North Carolina taxable wage base. This entry cannot be more than 
         item 2. Example: An employer using the 2023 taxable wage base of $29,600 and reporting one employee, John Doe, earning $8,000 per quarter. 
                             1ST QTR                    2ND QTR         3RD QTR                               4TH QTR 

              ITEM 1:        $8,000.00                  $8,000.00                         $8,000.00           $8,000.00 

              ITEM 2:                        -0-              -0-                                  -0-        $2,400.00 

              ITEM 3:        $8,000.00                  $8,000.00       $8,000.00                             $5,600.00 
         3:  Subtract Item 2 from Item 1. THE RESULTS CANNOT BE A NEGATIVE AMOUNT. 
         4:  Multiply Item 3 by the tax rate shown on the face of this report. (Example: .012% = .00012) 
         If the tax due is less than $5.00, you do not have to pay it, but you must file a report. 

         5:  Enter Interest – Late if Filing 
         6:  Enter Penalty – Late Filing 

         7. Enter Penalty – Late Payment

                 Note:  Numbers 5, 6 and 7 MUST BE COMPUTED ONL Y IF THE REPORT IS NOT FILED  (POSTMARKED) BY THE DUE DA TE. 

         8: Multiply the tax due (Item 5) by the current interest rate for each month, or fraction thereof, past the due date. The applicable interest rate may be obtained at 
         des.nc.gov or by contacting the nearest Division of Employment Security Office.  

         9: Multiply the tax due (Item 5) by 5% (.05) for each month, or fraction thereof, past the due date. 
         The maximum late filing penalty is 25% (.25). 

         10: Mul�ply the tax due (Item 5) by 10% (.1). The minimum late payment penalty is $5.00. ITEM 9: Enter the sum of Items 5, 6, 7 and 8. Remitance should be 
         made payable to the Division of Employment Security .
         11:  Enter this amount in box 1 on the NCUI-101

REV 11/23

                                                                                                                                                                                                                                                     SOC .
                                                                                                                                                                                                                                                                         13           CODE

     PAGE             NUMBER

                                                                                                                                                                                                         ACCOUNT NUMBER                                 LOCATION .
                                                                                                                                                                                                                                                                         12           SUMMARY

                                                                                                                                                                                                                                                    EMPLOYEE/ 11.
                                                                                                                                                                                                                                                                                      OFFICER

                                                                                                                                                                                                                                                     WAGE
                                                                                                                                                                                                                                                                         10.                 STATUS
                                                                                                                                                                                                                                                    RS
                                                                                                                                                                                                                                                    OU
                                                                                                                                                                                                                                     QUARTER-YEAR    H9.                                     WORKED

                                                                                                                                                                                                                                                    OUT OF 8. 
                                                                                                                                                                                                                                                                                      STATE         CODE

                                                                                                                                                                                                                                                    OUT OF STATE 7.
                                                                                                                                                                                                                                                                                      TAXABLE WAGES       $ 0.00

                                                                                                                                                                                                                                                                 6. GROSS       WAGES 
                                                                                                                                                                                                                                                                             *                            $ 0.00
                                                                                                                                                                                                                        EMPLOYER NAME

                            CONTINUATION SHEET FOR

                                                                                  REPORT OF EMPLOYEES WAGES                                                                                                                                                                                                     14.TOTALS
                                                                                                            RETURN THIS PAGE IF NEEDED TO COMPLETE REPORT
                                                                                                                                                                                                                                                                    NAME
                                                                                                                                                                                                                                                                    FIRST
                                                                                                                                                                                                                                                                          5.
                                                                                                                                                                                                                                                                             *

                                                                                                                                                                                                                                                                   NAME

                                                                                                                                                                                                                                                                   LAST  .4                                                       
                                                                                                                                                                                                                                                                             *                                                    -B

                                                                                                                                                                                                                                                                                                                         NCUI 101

                                                                                                                                                                                                                                                                                                                                    /23
                                                                                                                                                                                                                                                                   SSN3.                                                            11
                                                                                  0. BOX 26504                                                                                                                                                                               *                                                      REV 
NC DEPT. OF COMMERCE                              DIVISION OF EMPLOYMENT SECURITY P.                        RALEIGH, NC 27611-6504                                    TYPE INFO AS SHOWN ON FORM NCUI 101